MedicareCommons™

Neutral. Transparent. Retrieval-first.

array(20) { ["plan_name"]=> string(28) "Wellcare Giveback Open (PPO)" ["plan_id"]=> string(9) "H1914-002" ["org_name"]=> string(8) "Wellcare" ["plan_type"]=> string(9) "Local PPO" ["region"]=> string(18) "All counties in CT" ["moop"]=> string(12) "Data missing" ["deductible"]=> string(12) "Data missing" ["inpatient_hospital"]=> string(125) "$725.00 (days 1–3), $0.00 (days 4–90), $0.00 (days –)
Prior Authorization Required, Referral Required" ["snf"]=> string(132) "$0.00 (days 1–20), $197.00 (days 21–60), $0.00 (days 61–100)
Prior Authorization Required, Referral Required" ["pcp"]=> string(47) "$0.00 Copay
Referral Required" ["specialist"]=> string(78) "$15.00 Copay
Prior Authorization Required, Referral Required" ["urgent_care"]=> string(78) "$35.00 Copay
Prior Authorization Required, Referral Required" ["er"]=> string(81) "30% Coinsurance
Prior Authorization Required, Referral Required" ["ambulance_ground"]=> string(79) "$300.00 Copay
Prior Authorization Required, Referral Required" ["ambulance_air"]=> string(79) "$300.00 Copay
Prior Authorization Required, Referral Required" ["dental"]=> string(73) "$0.00 max
$0.00 max
Referral Required" ["vision"]=> string(114) "$0.00 Copay
$100.00/yr eyewear
Prior Authorization Required, Referral Required" ["hearing"]=> string(47) "Not Covered
Referral Required" ["rx"]=> array(2) { ["deductible"]=> string(7) "$420.00" ["tiers"]=> array(6) { [0]=> array(11) { ["order"]=> int(1) ["name"]=> string(29) "Preferred Generic*" ["deductible"]=> string(8) "Excluded" ["deductible_flag"]=> string(8) "Excluded" ["retail_30"]=> string(11) "$5.00 Copay" ["retail_90"]=> string(12) "$15.00 Copay" ["mail_30"]=> string(11) "$5.00 Copay" ["mail_90"]=> string(12) "$15.00 Copay" ["ltc_30"]=> string(11) "$5.00 Copay" ["out_network"]=> string(11) "$5.00 Copay" ["post_oop"]=> string(11) "$0.00 Copay" } [1]=> array(11) { ["order"]=> int(2) ["name"]=> string(19) "Generic*" ["deductible"]=> string(8) "Excluded" ["deductible_flag"]=> string(8) "Excluded" ["retail_30"]=> string(12) "$10.00 Copay" ["retail_90"]=> string(12) "$30.00 Copay" ["mail_30"]=> string(12) "$10.00 Copay" ["mail_90"]=> string(12) "$30.00 Copay" ["ltc_30"]=> string(12) "$10.00 Copay" ["out_network"]=> string(12) "$10.00 Copay" ["post_oop"]=> string(11) "$0.00 Copay" } [2]=> array(11) { ["order"]=> int(3) ["name"]=> string(15) "Preferred Brand" ["deductible"]=> string(7) "Applies" ["deductible_flag"]=> string(7) "Applies" ["retail_30"]=> string(15) "25% Coinsurance" ["retail_90"]=> string(15) "25% Coinsurance" ["mail_30"]=> string(15) "25% Coinsurance" ["mail_90"]=> string(15) "25% Coinsurance" ["ltc_30"]=> string(15) "25% Coinsurance" ["out_network"]=> string(15) "25% Coinsurance" ["post_oop"]=> string(11) "$0.00 Copay" } [3]=> array(11) { ["order"]=> int(4) ["name"]=> string(18) "Non-Preferred Drug" ["deductible"]=> string(7) "Applies" ["deductible_flag"]=> string(7) "Applies" ["retail_30"]=> string(15) "44% Coinsurance" ["retail_90"]=> string(15) "44% Coinsurance" ["mail_30"]=> string(15) "44% Coinsurance" ["mail_90"]=> string(15) "44% Coinsurance" ["ltc_30"]=> string(15) "44% Coinsurance" ["out_network"]=> string(15) "44% Coinsurance" ["post_oop"]=> string(11) "$0.00 Copay" } [4]=> array(11) { ["order"]=> int(5) ["name"]=> string(9) "Specialty" ["deductible"]=> string(7) "Applies" ["deductible_flag"]=> string(7) "Applies" ["retail_30"]=> string(15) "28% Coinsurance" ["retail_90"]=> string(3) "—" ["mail_30"]=> string(15) "28% Coinsurance" ["mail_90"]=> string(3) "—" ["ltc_30"]=> string(15) "28% Coinsurance" ["out_network"]=> string(15) "28% Coinsurance" ["post_oop"]=> string(11) "$0.00 Copay" } [5]=> array(11) { ["order"]=> int(6) ["name"]=> string(18) "Tier 6*" ["deductible"]=> string(8) "Excluded" ["deductible_flag"]=> string(8) "Excluded" ["retail_30"]=> string(11) "$0.00 Copay" ["retail_90"]=> string(11) "$0.00 Copay" ["mail_30"]=> string(11) "$0.00 Copay" ["mail_90"]=> string(11) "$0.00 Copay" ["ltc_30"]=> string(11) "$0.00 Copay" ["out_network"]=> string(11) "$0.00 Copay" ["post_oop"]=> string(11) "$0.00 Copay" } } } ["data_status"]=> string(2) "ok" }
🩺 Doctor’s Office Visits
Service 2026 2025
PrimaryComing soon$0.00 Copay
Referral Required
SpecialistComing soon$15.00 Copay
Prior Authorization Required, Referral Required
🏥 Emergency, Urgent, and Inpatient Hospital Coverage
Service 2026 2025
Emergency room careComing soon30% Coinsurance
Prior Authorization Required, Referral Required
Urgent careComing soon$35.00 Copay
Prior Authorization Required, Referral Required
Ground ambulanceComing soon$300.00 Copay
Prior Authorization Required, Referral Required
Inpatient hospital careComing soon$725.00 (days 1–3), $0.00 (days 4–90), $0.00 (days –)
Prior Authorization Required, Referral Required
Skilled Nursing FacilityComing soon$0.00 (days 1–20), $197.00 (days 21–60), $0.00 (days 61–100)
Prior Authorization Required, Referral Required
🦶 Foot Care
Service 2026 2025
Foot Exams and Treatments (Medicare-covered)Coming soon20% Coinsurance
Referral Required
Routine Foot CareComing soon0% - 20% Coinsurance
Prior Authorization Required, Referral Required
💆 Chiropractic Care
Service 2026 2025
Medicare-covered chiropracticComing soon20% Coinsurance
Prior Authorization Required, Referral Required
Routine chiropracticComing soon20% Coinsurance
Prior Authorization Required, Referral Required
🧠 Mental Health Services
Service 2026 2025
Outpatient individual therapyComing soon$15.00 Copay
Referral Required
Outpatient group therapyComing soon$15.00 Copay
Referral Required
Inpatient psychiatric hospital careComing soon$675.00 (days 1–3), $0.00 (days 4–90), $0.00 (days –)
Prior Authorization Required, Referral Required
🏋️ Rehabilitation Services
Service 2026 2025
Physical therapy and speech/language therapyComing soon$35.00 Copay
Prior Authorization Required, Referral Required
Occupational therapyComing soon$35.00 Copay
Prior Authorization Required, Referral Required
🧰 Medical Equipment and Supplies
Service 2026 2025
Diabetes suppliesComing soon$0.00 Copay
Prior Authorization Required, Referral Required
Durable medical equipmentComing soon$35.00 Copay
Prior Authorization Required, Referral Required
ProstheticsComing soon$0.00 - $35.00 Copay
Prior Authorization Required, Referral Required
🔬 Diagnostics, Lab Services, and Imaging
Service 2026 2025
Diagnostic radiology servicesComing soon$35.00 Copay
Prior Authorization Required, Referral Required
Lab servicesComing soon$35.00 Copay
Prior Authorization Required, Referral Required
Outpatient x-raysComing soon$0.00 - $40.00 Copay
Prior Authorization Required, Referral Required
Diagnostic tests and proceduresComing soon$35.00 Copay
Prior Authorization Required, Referral Required
💉 Medicare Part B Drugs
Service 2026 2025
ChemotherapyComing soon$0.00 Copay
Prior Authorization Required, Referral Required
Other Part B drugs (Medicare-covered)Coming soon20% Coinsurance
Prior Authorization Required, Referral Required

Supplemental Benefits

🦷 Dental Services
Service 2026 2025
Medicare Covered Preventive DentalComing soon$0.00 max
$0.00 max
Referral Required
Oral examComing soon$0.00 Copay
Referral Required
Dental x-raysComing soon$0.00 Copay
Referral Required
CleaningComing soon$0.00 Copay
Referral Required
PeriodonticsComing soonNot Covered
Referral Required
EndodonticsComing soonNot Covered
Referral Required
Restorative ServicesComing soonNot Covered
Referral Required
Dental MaximumComing soonNot Covered
👂 Hearing Aids and Services
Service 2026 2025
Fitting/evaluationComing soon$0.00 Copay
Referral Required
Hearing aidsComing soon$0.00 Copay
Referral Required
Hearing examComing soon$0.00 max
$0.00 max
Prior Authorization Required, Referral Required
Hearing MaximumComing soon$0.00 max
👓 Vision Services
Service 2026 2025
Medicare-covered eye examComing soon$0.00 max
$0.00 max
Prior Authorization Required, Referral Required
Routine eye examComing soon$0.00 Copay
Referral Required
Eyewear benefitsComing soon$0.00 Copay
Referral Required
Vision Eyewear MaximumComing soon$100.00/yr eyewear
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Part D Plan Premium

The Part D prescription drug plan premium is included in your overall Medicare Advantage plan cost. However, additional expenses or subsidies may apply through the Low-Income Subsidy (LIS) program, also known as Extra Help. LIS, provided by Social Security, helps those with limited income and resources to lower or eliminate Part D costs. LIS benefits are not part of Medicare Advantage coverage.

{name} Prescription Drug Plan Premium Details
Basic Part D Premium: ${part_d_basic_premium}
Supplemental Part D Premium: ${part_d_supplemental_premium}
Total Part D Premium: ${part_d_total_premium}
Low-Income Premium Subsidy: ${part_d_lips_amount}
Low-Income Premium Subsidy Paid by CMS: ${part_d_lips_cms_pays}
Low-Income Subsidy Premium: ${part_d_lis_premium}

For more details, visit the Social Security Extra Help program.

Prescription Drug Plan Deductible

This plan has a ${deductible} annual Part D deductible. You'll pay this deductible at the pharmacy before {carrier} starts contributing towards your prescription costs.

Prescription Drug Plan Out-of-Pocket Costs

Beyond premiums and deductibles, {name} may have additional costs at pharmacies. The table below outlines out-of-pocket expenses by drug tier.

{name} Pharmacy Out-of-Pocket Costs by Drug Tier
Drug Tier Retail Mail Order
Preferred Generic<sup>*</sup>30-day: $5.00 Copay
90-day: $15.00 Copay		30-day: $5.00 Copay
90-day: $15.00 Copay
Generic<sup>*</sup>30-day: $10.00 Copay
90-day: $30.00 Copay		30-day: $10.00 Copay
90-day: $30.00 Copay
Preferred Brand30-day: 25% Coinsurance
90-day: 25% Coinsurance		30-day: 25% Coinsurance
90-day: 25% Coinsurance
Non-Preferred Drug30-day: 44% Coinsurance
90-day: 44% Coinsurance		30-day: 44% Coinsurance
90-day: 44% Coinsurance
Specialty30-day: 28% Coinsurance
90-day: —		30-day: 28% Coinsurance
90-day: —
Tier 6<sup>*</sup>30-day: $0.00 Copay
90-day: $0.00 Copay		30-day: $0.00 Copay
90-day: $0.00 Copay
*Deductible does not apply.